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Radiology Coding Alert

Reader Questions:

Focus on 465.x for URI

Published on Sun May 09, 2010

Question: An adult patient presented for a two-view chest X-ray. The record noted wheezing, coughing, and trouble catching her breath. The ordering physician documented focal rhonchi and  rdered the X-ray to check for upper respiratory infection (URI). The chest X-ray results revealed acute URI. How should I code this case?Kansas SubscriberAnswer: For the X-ray, you should report 71020 (Radiologic examination, chest, 2 views, frontal and lateral). Connect 71020 to the appropriate URI ICD-9 code, based on your documentation. If no specific site or sites are documented, you'll need to use nonspecific code 465.9 (Acute upper respiratory infections of multiple or unspecified sites; unspecified site).To further support the chest X-ray, ICD-9 guidelines allow you to report the signs and symptoms as secondary diagnoses. For example, you may report 786.7 (Symptoms involving respiratory system and other chest symptoms; abnormal chest sounds) for the rhonchi, which are snore-like sounds caused by the narrowed airway.The [...]
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